Copyright
Copyright © 2019 by Steffanie Strathdee and Thomas Patterson
Cover design by Amanda Kain
Cover image © Omikron/Getty Images
Cover copyright © 2019 by Hachette Book Group, Inc.
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Library of Congress Control Number: 2018960533
ISBNs: 978-0-316-41808-9 (hardcover); 978-0-316-41811-9 (trade paperback); 978-0-316-41807-2 (ebook)
E3-20200923-JV-PC-REV
CONTENTS
Cover
Title Page
Copyright
Dedication
Epigraph
PART I
A Deadly Hitchhiker
Blindsided
1. A Menacing Air
2. The Last Supper
3. Disease Detectives
4. First Responders
5. Lost in Translation
6. The Colonel from Al-Shabaab
Tom: Interlude I
7. A Deadly Hitchhiker
8. “The Worst Bacteria on the Planet”
Tom: Interlude II
PART II
Can’t ESKAPE
9. Homecoming
10. Superbugged
11. Public Enemy Number One: Under the Radar
Tom: Interlude III
12. The Alternate Reality Club
13. Tipping Point: Fully Colonized
Tom: Interlude IV
PART III
The Perfect Predator
14. The Spider to Catch the Fly
Tom: Interlude V
15. The Perfect Predator
16. Semper Fortis: Always Faithful, Always Strong
17. A Hail Mary Pass
18. Panning for Gold
19. Journeying
Tom: Interlude VI
PART IV
The Darwinian Dance
20. The Blood Orange Tree
21. Moment of Truth
22. The Bold Guess
23. Lysis to Kill
Tom: Interlude VII
24. Second-Guessing
25. No Mud, No Lotus
Tom: Interlude VIII
26. The Darwinian Dance and the Red Queen’s Pursuit
27. The Last Dance
28. The Buddha’s Gift
29. Grand Rounds
Epilogue
Photos
Acknowledgments
About the Authors
Perfect Predator Discussion Guide Questions
To Readers
Selected Chapter References
Praise for The Perfect Predator
Newsletters
To our children,
Carly, Frances, and Cameron
Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads from a blue sky. There have been as many plagues as wars in history; yet always plagues and wars take people equally by surprise.
—Albert Camus, The Plague
Drawing of a T4 myophage, similar to several of the bacteriophages used to treat Tom. Drawing by Ben Darby
PART I
A Deadly Hitchhiker
We stopped looking for monsters under our bed
when we realized that they were inside us.
—Attributed to Charles Darwin
Drawing of a T7 podophage, similar to the “superkiller” bacteriophage used to treat Tom. Drawing by Ben Darby
BLINDSIDED
University of California–San Diego
Thornton Hospital, La Jolla
February 15, 2016
I never dreamed I’d be outwitted by a wimpy bacterium. I’d tracked a killer virus across multiple continents to wage the war against AIDS, through the trenches and at the table with policymakers at a global level. Viruses were to be feared. Bacteria? Not so much. At least not this one. I’m an infectious disease epidemiologist, director of a global health institute at a major US university, and of all people, I should have been able to protect my husband from a bacterium I’d last seen in my undergrad days, when we’d handled it without concern in basic lab experiments. If someone had told me that one day this microbial mutant would have us on death watch and I’d soon be injecting my husband with a legion of killer viruses to try to save him, I would have thought they’d lost their marbles. And yet, here we are.
The holidays—Thanksgiving, Christmas, New Year’s, and Valentine’s Day—have passed in a blur. Tom is hardly recognizable beneath the web of IVs, monitor cables, drains, tubes, and other medical paraphernalia. His once thick silver hair, which stylists swooned over, has fallen out in clumps, and the skin on his feet and hands is peeling off in layers. He has lost more than a hundred pounds from his six-foot-five-inch frame. We have not lost hope, and on this day, like every day, we are strategizing how to beat this thing. But at this moment I am doing it on my own. Tom is lapsing in and out of consciousness, an improvement over the coma, but still…
The tone of the clinical conversation among the specialists and other medical staff around Tom has changed in some subtle way. It’s hard to nail down. His labs and vital signs fluctuate as they have for three months now, so it’s not that. It’s something between the lines, something they’re not saying, that I’m unable to decipher. Since our lives went from bliss to hell in a handbasket, it’s been all I could do to learn enough about anatomy and medicine just to keep up with their conversation. I’m a researcher, not a doctor, but even I know something about bedside manner. And theirs has shifted.
Now, the doctors and nurses speak in hushed tones and some seem afraid to look at me. In short snippets, between running exchanges with doctors and hospital staff, I turn to the internet, where I enter phrases like “alternate treatments” and “multi-drug-resistant bacteria” into PubMed, a search engine beloved by scientists. Ordinarily, my online searches are specific and hyperfocused because I usually know what I am looking for—like “prevention” and “HIV transmission” and “injection drug use.” But right now, I’m not so much an epidemiologist as I am the wife of a very sick man. I’m not sure what the operative questions should be, or what a useful answer might look like. And what’s freaking me out is that none of the docs treating Tom seem to know, either.
What’s obvious at first glance in the scientific literature just confirms what we already know: Tom is up against, as one study says, “a difficult-to-treat pathogen whose antibiotic resistance patterns res
ult in significant challenges for the clinician.” No shit, Sherlock. What we’ve got here is one of the most lethal bacteria known to humankind, a “superbug,” that has mutated to resist all existing antibiotics. Recent advances in exploratory research on how to fight this superbug have all been experimental, meaning that there was insufficient data to prove that they worked, so none were approved for general use, leaving Tom’s docs at a dead end in their hunt for approved treatment options. Among novel ideas out there was an approach I vaguely remember studying briefly as an undergrad—the use of viruses that prey on bacteria—but that idea appears to be nothing more than a footnote in the margins of modern medicine.
Tom lies motionless, the steady hum and beeps of monitors the only sign of life, and I try to distract myself, emailing our graduate students about their latest papers from the corner of his room. In my busy mode, trying to keep at least a nominal tether to the real world, I dial in to a conference call to join my senior colleagues on a university retreat in San Francisco. I was supposed to be there, too. But in the months since the war against pandemics took a personal turn, everyone we know has heard what Tom and I are up against and where we’re holed up. Several of my colleagues ask how Tom is doing. I give them the latest rundown before telling them that I have to ring off. We say our goodbyes, and as I get ready to hang up, the chair of the meeting, a retired surgeon and former university chancellor, asks a question quietly to my colleagues, thinking I’m no longer on the phone.
“Has anyone told Steff that her husband is going to die?”
1
A MENACING AIR
12 weeks earlier
November 23–27, 2015
It had all started out so ordinary. Well, ordinary for a couple of globetrotting scientists who go looking for trouble in the world of infectious diseases.
Egypt hadn’t seemed like a dangerous place to go when we’d started planning our dream vacation, but a month before we left, a plane was blown up near Sharm El Sheikh, Egypt’s famous beach community. A few weeks later, a series of orchestrated terrorist attacks in France shook Europe to its core, with blame cast on extremists in the Middle East and Northern Africa. The tourist industry in Egypt took a nosedive. By Tom’s logic, it was the perfect time to go.
Given the circumstances, I had suggested to Tom a few times that we cancel, but we’d both just launched several new research projects and were desperate for some downtime. Admittedly, our threshold for risk is a little higher than the average Joe. Our research on risk factors for HIV, sex work, and drug use routinely takes us to places where disease and street violence are everyday facts of life—and death—for many people. For thirty years before that, Tom’s field work in evolutionary biology had taken him to some of the most remote places on earth, where humans weren’t the favored species for survival.
As a “second time around” couple now married eleven years, our kids were grown. We were empty nesters with a passion for travel. We’d been to more than fifty countries between the two of us, frequently presenting our research at an international conference and then tacking on a few personal days for a getaway. Our adventures often included unexpected challenges. We’d fended off a rogue hippo from a dugout canoe on the Zambezi, and in India, glistening ribbons of leeches in Kerala and giant jumping spiders in Orissa. We’d narrowly missed a terrorist attack in Mumbai and a violent coup in Timbuktu, and encountered drug cartel henchmen and police on the take in our field research. We’d long since accepted that our work came with risks, and travel did, too. That was the fun part.
Tom, in particular, had a deep interest in ancient Egyptian history, art, and culture. He had wanted to do this trip so badly for so long, and we’d had to scuttle plans before. So our excitement at finally getting to go eclipsed any other considerations. But after the attacks on Sharm El Sheikh and Paris, even well-traveled friends had raised their eyebrows when we told them we were passing up their invitations of Thanksgiving dinner for the pyramids. My parents, who had flown in from Toronto to house-sit, were a tad more outspoken.
“Bad things come in threes,” my mother cautioned, as she finished chopping a fennel bulb for our dinner salad, paused to play Candy Crush Saga on her iPad, then resumed chef’s duty. “Hope number three doesn’t happen in Egypt,” she said ominously, motioning with the point of her knife to the CNN footage of the Paris attacks.
Spontaneity had always been a common denominator for us in our travels, and we liked to meet nature on its own terms. Eleven years earlier, Tom had proposed to me as we walked along the beach in Del Mar during the bioluminescent tide, when a particular species of phytoplankton glows blue-green as it’s roughed up in the surf. The shimmering ripple kissed the beach and made our footprints glow, a nice romantic touch. The thing is, this kind of bioluminescence is also a marker, a warning of sorts, of the marine plankton that lurks invisibly below it, causing a toxic algae bloom known as the red tide. That pretty much summed up our life view as a couple: bask in the glow, and deal with what lurks below when the time comes. Work hard, play hard.
We were married later that year by our children in an offbeat civil ceremony at a beach house in Hawaii. At the time, Tom’s daughters, Carly and Frances, were twenty-one and seventeen, respectively. My son Cameron was twelve. I bought leis, grass skirts, and coconut shell bra tops for the girls. When Cameron pouted that he didn’t have a wedding outfit, I bought him a set, too. Back then, he’d sulked about his dad and me divorcing, and he seemed noncommittal about my plans to marry again. Thankfully, when we overheard his side of a phone conversation with a schoolmate, he’d said, “Yeah, I am going to have two sisters, but they’re cool; one even has dreadlocks!” Carly, who had yet to shear her shoulder-length dreadlocks, had become a mail-order minister through the Universal Life Church. When I teased her about it, I learned that Tom had been similarly ordained decades before in one of his repeated attempts to dodge the Vietnam War. As Carly presided over our wedding ceremony with Cameron and Frances standing solemnly on either side of us, hands clasped and grass skirts swaying, Tom and I clinked Champagne glasses. For a couple who, as individuals, had grown from humble origins and through hard times in a number of other ways, we felt we’d led a charmed life ever since.
That night, as we finished packing to leave for Egypt in the morning, I set out keys to the house and car; directions for tending the cat, the garden, the bird feeders, and the worm composter; and instructions to the remote controls for the TV. Then I did something I had never done before. At the last minute, I penned a single page of notes that began with the words “In the event of our death…” Tom rolled his eyes skyward, but he scribbled his signature on the bottom beside mine. I read it again once through and placed it neatly on the kitchen island alongside the car keys.
Taking the advice of friends, we’d found a respected Egyptologist to be our guide, trading our improvisational habit for a more intentional learning experience. An uneventful flight left us eager to start the day’s itinerary when we met Khalid the next morning. A lithe, petite man who looked to be around forty, Khalid wore khakis, a button-down plaid shirt, and worn but very well polished shoes. He approached us with an outstretched hand and a warm smile to welcome us to Cairo. Khalid had been a guide for several documentary crews and scholarly expeditions, and he would be ours for the next week through an ambitious itinerary of pyramids, temples, tombs, and other ancient sites.
Each morning Khalid picked us up and, as we drove into the desert or hiked through ruins, spoon-fed us a condensed version of thousands of years of Egyptology, archeology, and mythology. In his stories, he wove together tales of the kings and pharaohs, their tombs, and the pyramids in a lively narrative that merged bricks and mortar with ancient mysticism. So it was that each day we were immersed in a realm where the grand and ancient architecture and liturgy of death came alive for us, from mummies frozen in time to the fantastical hieroglyphics that told their tales—the graphic novels of their time.
On what was Thanksgiving Day b
ack home, we toured several ancient ruins within a few hours from Cairo, Egypt’s modern-day capital and vibrant metropolis home to more than seven million people. Virtually all of these sites were what Egyptologists call a necropolis. In other words, mass burial graves.
Inside one museum, Khalid showed us hieroglyphics painted on a sarcophagus that outlined the process of mummification. They included multiple depictions of Anubis, who had the body of a man and the head of a jackal. Anubis was the Egyptian god of the dead, responsible for presiding over embalming and mummifying bodies, ushering souls to the afterlife, and protecting their graves from robbers and demons. Also depicted were intricate, oddly shaped tools for the task of preparing bodies for the next realm. Tom shuddered at the sight of them, never one for gruesome clinical detail, even when it’s five thousand years old. I found them fascinating.
“What’s that one for?” I asked Khalid, pointing to a strange little hook that a thousand-year-old dentist might wield to pull an errant tooth. Khalid looked up at us with a hint of a grin.
“That one’s for removing people’s brains,” he replied. “Through their nose. To preserve the skull. Without a preserved body, the ancient Egyptians believed there would be no home for the soul in the afterlife, and its ghost would be forced to haunt its family members.”
If the ancient Egyptians seemed to have been overly preoccupied with death and funeral preparation, it was because they believed the spirit faced a perilous journey to reach the afterlife and settle in for eternity. I could appreciate their desire for a smooth journey and their abundance of caution to ensure it. Tom might scoff at my thorough notes for house sitters, but as an evolutionary biologist he had to appreciate that it’s only human.
About an hour south of Cairo, we made our way to the royal desert necropolis of Dahshur and the Red Pyramid, the largest of three pyramids neighboring a military base. Because of its proximity to the base, the pyramid had been closed to tourists for many years, and even now was not always open. But we’d lucked out; it was open today and there was no one else in sight. Khalid said it was possible to crawl inside the tunnels for a close-up view. Ignoring the heat and swirling red dust, Tom and I raced to see who would be first to explore the pyramid. To reach the entrance we first had to climb several steep staircases that zigzagged up the face of the pyramid to a makeshift door, several hundred feet above the ground. Tom is nineteen years my senior, but you wouldn’t know that from looking at him. Tall, with broad shoulders and a natural athleticism, he’d always been fit—a diehard surfer undaunted by the risk of “going over the falls” in “wave architecture” with dubious descriptors like “gnarly” and “walled up.” From lanky youth to a sturdier middle age, Tom was always among the first to get into the water when storms or wild waves made retreat a reasonable option. He rarely considered retreat a reasonable option, period.
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